Abstract
Presents evaluations of two projects implemented by the International Eye Foundation (IEF) in Malawi's Chikwawa District -- a final evaluation of a project (2/96-9/99) to integrate AIDS and family planning (FP) services (STAFH project), and a mid-term evaluation (4/98-9/99) of the Community Health Partnerships (CHAPS) project. The STAFH project focused on mobilizing behavior change and on assuring ongoing service availability, emphasizing HIV/AIDS prevention and FP. The project covered a variety of target groups and a variety of partners for reaching them. CHAPS, by contrast, works exclusively through the Ministry of Health (MOH), with a focus on capacity building and assuring service availability at the community level. The range of potential interventions is as wide as the MOH itself, but strengthening management and support systems provides the framework for these activities. STAFH was competently implemented and made good progress towards all of its objectives. Highlights include: an increased contraceptive prevalence rate, particularly in villages with community-based distribution (CBD) of contraceptives; increased competency of clinical staff in treating sexually transmitted diseases (STDs) and in supervising community distributors; increased access to FP methods, both in the community and at health centers; and increased depth and breadth of knowledge about AIDS and FP. Shortfalls were due more to gaps in project design, particularly unclear definition of objectives and lack of activity support systems, than to implementation problems. Significant accomplishments include: CBDs trained and active in community distribution of pills and condoms; providers trained and retrained in STD syndromic management; health surveillance assistants (HSAs) trained in HIV/AIDS and FP, including supervision of CBDs; traditional healers trained in HIV/AIDS prevention and modern FP methods; partnerships established supporting peer educators in Sucoma and home-based care (HBC) volunteers and counseling at Montfort Hospital; and pilot efforts in training traditional initiation counselors and educating politicians in HIV/AIDS prevention. The no-cost extension allowed for a seamless transition of STAFH into CHAPS and its system-strengthening model in partnership with the MOH. General conclusions regarding CHAPS are as follows: (1) The first year of the project was frustrating for everybody. The District Health Management Team (DHMT) was not functioning and IEF staff had no authority in the District. Without MOH leadership in the District, it was extremely difficult for the project to move forward. (2) CHAPS demonstrates a strong sense of ownership on the part of MOH, and the DHMT truly understands that CHAPS is a participatory team process. (3) The project has focused significantly on DHMT and community-level inputs, but has not addressed the problem of DHMT attrition and turnover. (4) Most community-level activities are well underway, with concurrent efforts to address supervision and supply systems. (5) Given the decentralization process occurring in Malawi, the CHAPS design (PVO/MOH partnership, mixed community- and system-level interventions, and mixed process and material inputs) works well and is very appropriate. (6) CHAPS objectives are appropriate, but 3 years is too short for a project of this scope. The biggest constraint facing CHAPS is the extreme shortage and turnover of human resources in Chikwawa District, particularly in leadership positions. While the project can help offset this disadvantage by strengthening management systems and policies, it cannot function in a vacuum. Human resource needs also need to be taken into consideration when assigning personnel at the national level. More specific recommendations are included.